Provider Demographics
NPI:1245809870
Name:SHRIDE, JOSHUA (ATC)
Entity type:Individual
Prefix:
First Name:JOSHUA
Middle Name:
Last Name:SHRIDE
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 S 1ST ST
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820-7661
Mailing Address - Country:US
Mailing Address - Phone:217-383-9400
Mailing Address - Fax:
Practice Address - Street 1:2300 S 1ST ST
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-7661
Practice Address - Country:US
Practice Address - Phone:217-383-9400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-18
Last Update Date:2021-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0960038552255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL096003855OtherIDPH
IL2000017540OtherBOC